Clinical research studyEffects of Clinical Pathways for Common Outpatient Infections on Antibiotic Prescribing
Section snippets
Study Setting and Population
The study was performed in a diverse group of Family Medicine and Internal Medicine outpatient clinics from the Distributed Ambulatory Research in Therapeutics Network (DARTNet) and Denver Health. DARTNet is a federated network linking patient-level clinical and pharmacy data from 86 organizations made up of 450 practices, 3000 clinicians, and more than 4.5 million patients.21 Electronic health records from DARTNet clinics are integrated into a single system provided by Clinical Integration
Results
Characteristics of the 8 participating clinics are described in Table 2. The study group included clinics with more providers (46 vs 34) and more patients served (52,766 vs 48,881) than the control group. Most index visits for the clinical pathway conditions were due to acute respiratory infections (68.0%-76.4%), and the proportions were similar during the baseline and intervention periods (Table 3).
The proportion of acute respiratory infections for which an antibiotic was prescribed decreased
Discussion
Unnecessary antibiotic prescriptions and use of overly broad-spectrum antibiotics remain common in the primary care setting. During the first year of this clinical pathway-based intervention, clinics randomized to the intervention prescribed antibiotics 11% less frequently for non-pneumonia acute respiratory infections and used broad-spectrum antibiotics 14% less frequently for all 8 clinical pathway conditions compared with the baseline period. Logistic regression models revealed significant
Conclusions
A widely generalizable clinical pathway-based intervention to improve antibiotic use for common outpatient infections modestly decreased antibiotic prescriptions for acute respiratory infections and overall use of broad-spectrum antibiotics during the first year. Further study is needed to evaluate the impact and sustainability of this intervention over a longer time period. Antibiotic use for acute bronchitis and rhinosinusitis was remarkably common despite the intervention and should be a
Acknowledgments
The authors thank John Ogle (Denver Health), Ralph Gonzales (University of California San Francisco), Adam Hersh (University of Utah), and Thea Carruth (HealthTeamWorks) for input on the clinical pathways, and Bryan Knepper and Carolyn Valdez (Denver Health), Elias Brandt, Wilson Pace, and Diane Fairclough (University of Colorado Denver) for assistance with data abstraction and statistical analyses.
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Cited by (44)
Targets and Methods to Improve Outpatient Antibiotic Prescribing for Pediatric Patients
2022, Infectious Disease Clinics of North AmericaThe costs incurred by the NHS in England due to the unnecessary prescribing of dependency-forming medications
2022, Addictive BehaviorsCitation Excerpt :The common focus on inappropriate or unnecessary medication use, including overuse, has been increasingly applied to various patient groups for whom interventions were not indicated or recommended (Miller et al., 2018). For example, such usage has been examined by several studies examining overuse in patients not requiring treatment, such as statins for primary prevention of cardiovascular disease (Byrne, Cullinan, & Smith, 2019); antibiotics for the treatment of viral upper respiratory infections (Jenkins et al., 2013), or acid suppressants for low-risk inpatients with specific conditions (Gupta et al., 2013). Questions regarding the over-use and unnecessary use of medicines has gained wide attention in the United Kingdom following the British Medical Journal’s Too Much Medicine campaign (Godlee, 2019), and a recent UK Government-commissioned review which estimated, on the basis of expert testimony, that 10% of items dispensed in NHS primary care are overprescribed, and are therefore unnecessary (DHSC, 2021).
Considerations for implementation: Pediatric outpatient antimicrobial stewardship program
2021, American Journal of Infection ControlAn Ambulatory Antimicrobial Stewardship Initiative to Improve Diagnosis and Treatment of Urinary Tract Infections in Children
2019, Joint Commission Journal on Quality and Patient SafetyEffectiveness of clinical pathway for upper respiratory tract infections in emergency department
2019, International Journal of Infectious DiseasesCitation Excerpt :Upper respiratory tract infection (URTI) is one of the leading causes of outpatient admission and antibiotic prescription (Shapiro et al., 2014; Sharma et al., 2017; Steinman et al., 2003). High rates of antibiotic consumption in URTI increase the risk of adverse events, healthcare costs, and antimicrobial resistance (Grijalva et al., 2009; Jenkins et al., 2013). Around half of the antibiotic prescriptions in the emergency department (ED) are either unnecessary or inappropriate (Jenkins et al., 2013).
From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting
2018, Current Problems in Pediatric and Adolescent Health CareCitation Excerpt :Decision trees flowed from initial presentation, to diagnosis, to treatment recommendations. Compared to practices in the control group, practices that employed the algorithms showed a significant reduction in antibiotic prescriptions for acute respiratory infections, and an overall decline in broad-spectrum antibiotic use.45 In a rural primary care setting, a large cluster randomized trial found similar results, with a marked decrease in macrolide use in particular.
Funding: Funding was provided by the federal Agency for Healthcare Research and Quality under Task Order Contract Number HHSA290200710008, Task Order No. 7 (Agency for Healthcare Research and Quality Task Order Officer: Michael Parchman, MD, Task Order Leader: Connie Price, MD). Dr Jenkins also was supported by the National Institute of Allergy and Infectious Diseases (1K23AI099082-01A1). The authors of this article are responsible for its content. No statement may be construed as the official position of the Agency for Healthcare Research and Quality of the US Department of Health and Human Services.
Conflict of Interest: None.
Authorship: All authors had access to the data and played a role in writing this manuscript.